Addressing Common Concerns about Habit Reversal Therapy (HRT/CBIT)

Many individuals with Tourette Syndrome (TS) or parents of children with TS have concerns about Habit Reversal Therapy (HRT). Many years back when my clinic, the Tourette Syndrome Program at Rutgers University was entering into communication with the researchers on HRT, we had our doubts as well. Not only have our doubts been put to rest, we are now involved in research on the effectiveness of HRT/CBIT. While no treatment works for everyone – HRT/CBIT for tics included – HRT is helpful in reducing tics for many children and adults. Still, any newly popularized treatment comes with its own set potential downsides. Here is a list of common concerns for HRT:

Will the efforts to do HRT for tics be too distracting and get in the way of other things?

Carrying out HRT strategies certainly takes work; it can at times be distracting, especially right at first. However, as an individual becomes accustomed to using their selected competing response for the target tic, it quickly becomes less and less distracting and becomes more of a habit. Consider a comparison to learning to drive a car. At first every little detail takes a lot of attention and energy. Over time, driving feels natural; little conscious thought is required and attention can be used for other tasks, such as talking to passengers, listening to the radio or looking at the scenery. Similarly, HRT is working well when the competing response is habitual: a natural response to a premonitory urge. When there is a big concern that HRT will be too distracting in certain settings, a skilled clinician will suggest that initial practice periods take place in environments where attention is less of a concern (e.g. during television time instead of during homework time).

Will the decrease in one tic led to the increase of other tics (or to new tics that replace the old ones)?

There is no evidence that using HRT for one tic will increase the amount of other tics. Instead, evidence suggests that HRT leads to a decrease in overall tics for most individuals. Of course, over time new tics tend to appear and overall tics tend to increase and decrease. This is the nature of TS (see section on What Might Happen with Tics over Time). In a successful HRT treatment, individuals can learn how to recognize that a new tic is coming on and decide to use HRT for this new tic even without being in treatment.

Will holding in tics at one time lead to a “rebound effect,” causing a burst of tics at another time?

Many parents have noticed predictable times where tics seem to be come out in a burst of tic activity that can be quite disruptive for their child. There are two very common versions of this scenario. One describes a child who has a lot more tics at home compared to other places, (e.g. school). Two describes a phenomenon where the moment child returns from school, there is a burst of tic activity. Parents witnessing this phenomenon might imagine that tics have to come out somewhere and that HRT will simply exacerbate these bursts of tics. As this is a legitimate concern, there is a good deal of research on the matter. Research indicates that inhibiting tics does not lead to rebound effects. HRT does not lead to rebound effects; it appears to lower overall tics, including tics within these periods of bursts. For an explanation of how these predictable tic bursts happen, please see my section on the Environmental Cueing of Tics.

Won’t the competing response become another tic?

For a lot of individuals, tics can easily emerge based on a commonly performed motion or sound. A good example of this is when the cough for a cold triggers a coughing tic well beyond the time when residual coughing should have ended. In HRT, competing response training directs an individual to perform an alternative, and usually incompatible action to their tic. For example, an individual with a head-shaking tic might be instructed to lean their head down and tense the muscles in the back of their neck every time they have the urge to head-shake. The concern is that the head-down/neck-tensing movement will become a tic that replaces the head-shaking tic. While this is a legitimate concern, we have never seen it occur in our clinic. The best explanation for why competing responses do not replace tics is that tics serve to relieve an uncomfortable urge (see my section on Premonitory Urges). The relief of discomfort is a powerful reinforcer that helps to maintain the tic over time. Competing responses serve to maintain an uncomfortable urge (that eventually goes away without performing the tic). As there is no reinforcement when a competing response is performed, it does not become habitual and does not become a tic over time.